WEEK 3

This week we said goodbye to our new friends Cheryl and Lauren from Michigan. They are an amazing mother, daughter duo who joined us the first two weeks and it was pretty sad to see them go after everything we had experienced together. So we all went out to dinner at the Bliss Hotel, where we had a few cold beers, lot’s of laughs and a few tears, as they climbed into the taxi.
On Wednesday we got up early all 5 of us squeezed into a car with no seat belts and only 4 seats for an hour and half bumpy ride on our way to Kopanga dispensary. We’ve grown accustom to squeezing more people and bags into a car than we ever thought possible, however this was our first experience with a LENGTHY car ride down a road that would be for ATV’s and motorcross only in the states. When we finally reached the clinic, we were dropped off on the side of the road and tramped our way through a field of cows and goats to the clinic.

Kopanga dispensary is a small mission clinic founded by the United Methodist Church in Washington state, around 1yr ago. The staff consists of a few nurses and nurse aids as well as a lab tech and an administrator. We were given the grand tour by the head nurse, who treats children under 5, the whole place consists of a labor room, a counseling/adult patient room, a Maternal Child Health room, a lab room, an observation room with four beds and a pharmacy room (the labor room and observation room are pretty large probably 15ft x 10ft, the other rooms are about 5ft x 7ft). The clinic takes 50 Kenyan shillings (ksh) for children under 5, 100ksh for children 6-13 and 200ksh for everyone 14 and older. This covers their evaluation, any lab tests and any medications prescribed. After our tour we each split off with a nurse to see some patients for a few hours and then were invited across the grounds to the guest house where we had tea and some lunch, which was prepared by a wonderful mother daughter team.

After lunch we decided since we were so close to the border of Tanzania we couldn’t possibly leave without venturing across. So we piled back into the car and journeyed down another bumpy red dirt road winding through the country side, passing small collections of mud huts with grass roofs and small children running alongside the car yelling “Msungu! Msungu!” and waving furiously. ( I just realized this is the first time I’ve mentioned this phrase and I have to apologize for this huge oversight, as this is one of the first words we learned because it means “white person” and everywhere… I mean EVERYWHERE we go, we hear it) So after about 30 minutes of driving we arrive at the border town where Mr. Barasa greeted the border guard, who looked like just everyone else except he had on a nice polo with the Kenyan flag embroidered on the upper left chest. After a few minutes Barasa got back into the car and we continued on into what Barasa called “no mans land” apparently there is a small section of land that doesn’t really belong to either country?? So after a few minutes we crossed over a small creek which we were told is the actual border, before arriving at the border town in Tanzania! We all quickly riffled through our bags to pull out our cameras to capture the moment and the signs, for proof of our entry when Mr. Barasa’s eyes bugged and “no, no, no, no.. it’s not like Kenya, no pictures”! Stunned we all shoved the cameras back in our bags and Barasa got out to speak with the border guard to see if we could enter the country. As he came back to the car smiling he says “ yes, it’s alright we can come in and we don’t have to pay to get back out” despite our mild shock and confusion at the prospect of having escaped a fee we didn’t know even existed we rolled along through the town.
On the side of the road towards the end of town a sign for the police station came into view and a stern looking gentleman in a khaki uniform with a rifle slung over his shoulder, glared at our car as we tried to turn around. He watched the car intently as the driver executed a 20 point turn, when the car was positioned exactly horizontal in the middle of the driveway he began to slowly stroll towards us. Small pangs of panic began to surge through me, Mr. Barasa jumped out of the car and greeted the man, who continued to look stern and glare at the car full of msungu’s. After only a few words exchanged the two strode up to the car and I prepared for the third degree. The guard, still stern with every step, stopped directly in front of my window, grabbed the door and busted out a wide toothy grin and a deep booming baritone said “You are welcome!” So our stay in Tanzania was brief but pleasant.

MASAI MARA!!! – Early Friday morning we left for our safari on the Masai Mara. We were told we would be taking a short cut to save time and get to the mara early, so we were all for it. It was the bumpiest most ridiculous ride, 10x worse and longer than the trip to kopanga! Thankfully we were in a van, but I really felt like I was going to rupture my spleen it was so rough. The holes and ditches on these roads are more along the lines of ravines, I seriously thought the car was going to bottom out, tip over, or break an axle! Finally we reached the Mara and before we got into the gates we saw water buffalo and zebras! Not even a mile past the gate and we saw elephants and were only a few feet from a herd of giraffe! It was amazing being so close to such magnificent animals in the wild. As our day came to a close we watched the sunset next to a pride of lionesses lazily napping next to a stand of trees.
Our accommodations in the tented camp were beyond expectation and just to put it in perspective, it was the BEST shower we’ve had since we arrived in Kenya! The food was delicious and a giant beer was only 200ksh. We were up early and out to watch the sunrise over the Mara, water buffalo, zebra, ostrich, topi, impala and tomi gazelle were all out grazing in the crisp morning air. We saw a lioness and four cubs cruise across the plains into some brush. Later in the morning we went back to the tent, packed up our things, took one last phenomenal shower and made our way down to the Masai village. The Masai are native people who still live in the traditional style on the Mara, houses made out of cow dung and all. The chief's son Peter was our guide and explained some of their cultural practices with us. Later the men and women danced and sang and we bought a few souvenirs from them. Tammy traded a headlamp for a necklace and Le traded her watch for a carved club. On our way out of the park we luckily happen across a cheetah resting beneath an acacia tree. She was beautiful and smaller than I had expected. This trip was definitely a high point of the rotation, don’t get me wrong I love the medicine but this was spectacular!!!

PS. - I just waited 30 minutes for 4 pictures to upload and when it reached 100% it failed, so no pictures tonight, sorry

Pictures

I couldn't upload pic's this time but I was able to load them on the other blog I'm doing here it is http://kenyamay2011trip.blogspot.com/

Kenya week 2:

Unfortunately our preceptor was unable to join us due to a family emergency, but lucky for us a member of the group Safe Passage to Motherhood (who were here 2 weeks before us working in Bware helping educate women about pregnancy, labor and delivery in an effort to decrease maternal/infant mortality) Lelinda (or Le ) volunteered to stay on with our group for another 2 weeks. Le is a clinical psychologist and her experience with the community as well as her specialty has been invaluable to us in the last week. We are all extremely grateful for her willingness to stay and help us process our experiences here in country.

Migori – The town itself is probably a medium sized town for Africa as it has a level 4 hospital (St. Joseph’s) and the main street has 2 supermarkets, 3 hardware stores and countless other shops. There are open market type of stands all over the side of the road and down side streets. It’s relatively safe to walk around the main street in town during the day, just be sure to keep your passport wallet on a string tucked safely inside your shirt and not wearing anything that looks valuable is a good idea. We always walk together in at least a pair but the larger the group the better. Last night some of the students from Medics to Africa program (they are staying in the hospital guest house further up the road) went out to a disco (night club) but we decided to stay in. Most of the time when you’re walking through town people are friendly and everyone greets you with “habari” (hello, how are things) to which you respond “mzuri or salama” (good, perfect) and they are big fans of the handshake! You shake hands with everyone, everytime you see them and the better you know them the longer the handshake is.

St. Joseph’s Mission Hospital – In a word… AMAZING… there are so many things about this place that are both inspiring and tragic. The people here are so welcoming and friendly; full of such love and kindness at times it overwhelms my heart to see how selflessly everyone here at the hospital gives to the point of exhaustion. The resources have made me cringe so many times I’m almost in a constant state of shock. At the same time they do their very best with the limited equipment and supplies they do have. The most significant thing about the hospital that stands out for me is how much death there is, for a hospital this size the number of patients that die every day is astounding. Most of the problem is that people wait so long before coming in, because of money or transportation, by the time they actually come in it’s nearly impossible to save them.

Bware – A quiet farming community just outside of Migori. We visited Bware primary school and the kids were absolutely adorable and so excited for the books, pencils, crayons, paper, erasers and other supplies we brought. By far the biggest hit was the football (soccer ball) we brought, they went crazy for that. Then we met with the Buchwa and BBEKAS ( Buchwa is the community health aids group that is made up of mostly women from the Bware community and BBEKAS, an acronym for all the primary schools in the area, is the headmasters from each school) had a meeting during which they gave us some information about the issues the community and the schools are facing and the things we could address while we are here.

After lunch we were taken to meet our host family, all three of us are staying with Alex and Lucy and their 2 daughters Angela (who is making me a skirt) and their 5 grandchildren Whitney, Willis, Vincent, Sharon and Wayne. We left our bags there and walked up the street with Le to visit the family she has been homestaying with. Marselline Koskei and her husband own 10 acres, their daughter Annett took us on a tour of their farm where they grow; bananas, mango, papaya, avocado, pineapple (Heather got to pick a fresh pineapple which we will enjoy tomorrow) soya (soy beans), ground nuts (peanuts), kale, maze (corn), napear grass (for the cows to eat), and cassava. After that we walked back down to Alex and Lucy’s where we enjoyed dinner and some entertainment provided by the children and then us as we tried to remember the Kiswahili words to the head, shoulders, knees and toes song. Then the two girls braided my hair, before we turned in for the night. The next day Le met us in the morning and we walked up the street to a neighbor’s house where a group of monkeys live in the nearby trees. Unfortunately we were too late in the day for monkey spotting, but the view from the top of the hill was breathtaking. When we got back to the house the children were all waiting to play with us Tammy played some football with the kids, the girls showed me how to weave grass and then Heather and I turned a jump rope for the girls and learned some Kenyan jumprope games. All in all it was a VERY good week.

This upcoming week we will be going on Safari Friday and Saturday so next time I should have some pics of the animals.

Karibu Kenya! Welcome to Kenya!

We arrived safe and sound on Monday 5/16/11 at around 6am, the Nairobi airport was easy to navigate as most all the signs are in English and Kiswahili. There was a station of visa applications and declaration forms in front of the visa/passport desk where we all double and triple checked our story and paperwork to make sure everyone was on the same page. We breezed through both visa and customs and took our first steps outside into the warm humid air. We were immediately met by our host and guide Mr. Barasa holding a “Ray of Hope” sign at the exit. He was warm and friendly and I couldn't have imagined a more generous and wonderful man to help us make the adjustment to life here in Kenya. We were then packed up into a matatu ( small van, like a VW bus) where Mr. Brarasa prayed over the next leg of our journey. The traffic here is unlike anything I have previously experienced it seems as if there are no laws what so ever, no right of way, few signals, and lot’s and lot’s of traffic! Vehicles weave in and out of lines up onto dirt paths where pedestrians are walking, motorcycles with three people riding, dart between cars and busses, it really feels like a free-for-all everywhere you go. After only 1 hour in traffic we passed through the first set of security gates where a row of white Mercedes benz and Toyota camery taxi cabs waited for fairs. Around the corner the tall green gates of the Musmark guest house where opened when the matatu driver honked signally the security/gate man of our arrival.

The lush greenery of the Musmark lines the driveway in and the charming old English style cottage greets you with a tall ivy covered chimney. The staff is amazing Judy our main hostess is very friendly and ready to help in anyway. The main house is used for meals which are freshly prepared and are always delicious, comprised of a mix of traditional African dishes like Ugali and more common familiar things like grilled chicken or fried Tillapia. Our room was located around the back of the main house past the enormous bright green lawn, large gazeebo and rich landscaped gardens. The room itself had three twin beds with mosquito nets over each, two medium size closets and a small bathroom with tub, shower, sink and W.C. toilet (which flushes, as opposed to the latreen which we ran into later).

Our first week in Nairobi was primarily for orientation, we had a few lectures in the meeting room at the Musmark and a few field trips during those days, though Monday was mostly spent sleeping.

Road safety (which will coincidentally be a major factor affecting our trip in a few days time) was our first lecture, given by Bright, a wonderful woman who works for SOMETHING an organization dedicated to improving traffic safety in developing countries. This is an important lecture, as the roads here are quite dangerous at times and you really need to be alert and always aware of your surrounding while walking ( and you will do A-LOT of walking). Kenya doesn’t really have a good emergency response system. Ambulances are few and far between on top of that they are just a taxi matatu with a stretcher, they are not staffed with trained personnel so there is no care provided to the patient enroute to the hospital. Most of the time it is good Samaritan’s who extricate the injured and the majority of the population have no concept of basic emergency care and sometimes actually do harm in an effort to help.

Masai Market – We experienced the main market on a Tuesday (there is another one on Saturdays, which is, I’ve been told, a little smaller and not as hectic) While the market itself is filled with a generous array of wonderful items that make great souvieniers; carved and painted bowls, antique and new masks, jewelry, scarves, t-shirts, carved statues, batiks, leather items, ect.. You will be OVERWHELMED not just in the variety of items but the attention you receive, be prepared to be swarmed by 5-6 men (think of the most aggressive, personable used car salesman you have ever experienced and multiply him by 5) and then barter like a miser. It is easy to get split up because you get surrounded, do not panic you are safe just keep an eye on where other people are ( it will be easy to tell, just look for the other giant group) These guys are middle men, brokering deals between you and the vendors, they will mark up the goods by thousands of shillings/hundreds of dollars. Barasa told us to counter offer 1/3 what they are asking and not to pay more than 1/2, my experience suggests that will work best with the vendors themselves, the middle men start too high for this, so I recommend having a ball park for what you think is reasonable in US dollars and start with ½ of that number. I also HIGHLY recommend really understanding the conversion and have a few numbers converted out so you can quickly ballpark it. (ie: when we were here it was 85:1 so roughly 500ks = 6$ 1,000ks = 12$ 5,000ks = 60$ 15,000 = 175$) unfortunately I didn’t have these estimates memorized until after the market. Also something I wish I had known is that if you really like something but the middle man price is to high and you walk away, when the middle men leave the vendors will find you and barter at a more reasonable price.

Kawangware – This slum is close to the Musmark and you’ll spend a day there touring the clinic, the learning center and visiting some of the homes of the children. It is an amazing experience, you will be moved to the point of tears many times that day and I can’t begin to describe all the things you will see and the impact it will have on you, so I won’t try. I will however give you some tips

– you can take pictures at the school, the kids and mama’s are honored to have their pictures taken when they first come down and sing for you. After that always ask first.

- You should put your camera away while walking through the slum and no pictures on the streets, you can take pictures of the kids parents and houses, but again ask first.

- it costs 500$/yr to sponsor a child through primary school - 800$/yr for secondary with an 8yr commitment for secondary.

- There will be a child that completely steals your heart, Cynthia stole mine.

Kiswahili lessons – Well worth the effort, Mariam is an excellent teacher she makes it fun to learn and is very patient with those of us who struggle. Kiswahili is pretty easy to learn and very easy to pick up at least a few phrases that will not only come in handy but win you lot’s of friends for you effort. Everything is pronounced just as it is written only vowel letters are read differently ( A = ah as in Kenya E= a vowel sound a I = vowel sound e, O is o, U = oo as in school ) so Asante for reading.

The trip to Migori – Our adventure began at 8am we all piled into a matatu and off we went. About 1.5hrs into the trip a car was trying to overtake (pass) another car and went off the road and down a steep embankment about 50-75ft. We stopped and everyone hopped out Tammy and Barasa ran down the hill while a few of us unpacked a first aid kit and a blanket for a stretcher. The patient was carried up the hill in a sheet and put into the back of a SUV driven by a British man who was familiar with the area and knew of a hospital that was close. Tammy and Barasa hoped into the SUV and provided care to the patient while the rest of our group followed in the matatu. Unfortunately the driver of our matatu lost sight of the SUV and did not know where the hospital was, to make matters worse he didn’t speak English and was lost. Eventually we made it to the hospital where we met up with Tammy and Barasa, by this time it was too late to continue on so we returned to the Musmark for the night.

The trip to Migori: Take 2 – Went off without a hitch. The trip is around 7 hour’s long, try to stay awake at least the first two hours because it will take you near the Masai Mara where we caught a glimpse of some zebra and giaraffe. The countryside on the way is beautiful, dotted with small communities every few kilometers. I recommend watching out the window and appreciating the beauty, instead of watching how the vehicle is driven, all the close calls, the anxiety and panic attacks.

Today was our first day at St. Joseph Mission Hospital, it was an amazing day! We were warmly welcomed by everyone at the hospital. After a brief meeting with administration and introductions to the clinical officers (Africa's version of PA's) Dr. Agullo took us right under his wing. We examined a few patients and walked over to the theatre (OR) and helped deliver a baby!! how's that for as Dr. Agullo called it "introduction by fire". After a tour of the entire hospital from the lab and pharmacy to the morgue and laundry we met virtually every staff member and were genuinely welcomed by each one. We then headed back up to sort all the items we packed and donated to the hospital. It's amazing how much we packed into those 50lb bags and it's apparent how grateful they are for each one.

It's been a long day so I am about to sit down to a wonderful meal prepared by our amazing house hostess Alice.

until next time, Utapona (be well )

The Day Shift.....

So after two weeks I think I have the day shift pretty much down, which definitely does not mean I am good at it. Day shift is VERY different than what I thought it would be, it's like more of hospitalist/internist medicine. As in you deal with a lot of internal medicine problems on all the trauma patients that have been admitted and are either recovering from or waiting to go to surgery. So my days look something like this...

6am - 6:15/30ish - sign out in the west wing ICU- night team gives you the run down on any problems your patients may have had over night and the scoop on any new admits on your assigned "wall" of the TRACU or upstairs (peds, ob and med surg)

6:15/30ish - 9am - sit in TRACU on a computer looking up all the morning labs, diagnostic imaging, reviewing other services consults or progress notes, seeing your patients (ie: physical exam) and writing notes on your patients. ( now this may seem like a long time, especially for me because I am only allowed to see at a max 5 patients, but trust me when the patient has a few chronic conditions on top of fractures, mental status changes, alcohol withdrawl symptoms, and electrolyte imbalances.. the time goes by waaay quicker than you think.) What is amazing to me is that in 2.5hrs these PA's can get most of their notes done on an average of 10 patients! They are AMAZING!!

9am - 12 (or sometimes 1,2 or even 3) Grand Rounds - yep, the big bad scary ground rounds of legend. Which actually turn out to not be so bad for the most part. But just like anything else it depends on the attending your rounding with. Some are slower than others, some teach as they go, some sit down with you after rounds and go over your notes with you. Presenting during rounds is still pretty rough for me, though after you've rounded with the attending once and know how they want you to present it's much easier and a little less intimidating. If I had one piece of advice it would be to WRITE down your lab values and do not be afraid of saying I DON'T KNOW. I don't know is always better than trying to bluff your way through something! I've watched it go very badly for people who try to do this and it is ALWAYS better to honestly answer any question, you will never ever be able to predict everything the attending will ask you so I try and write down as much of what I think is pertinent.

LUNCH - the PA's will usually make you go eat lunch even if rounds run over and clinic is waiting for you, on Friday's (even though that's usually your day off) there is a lecture from a couple residents that is interesting to attend if your there.

After rounds the rest of your scheudle depends on what day it is

T,W,Th - 1-5pm = Trauma clinic - it's fast paced, hectic and takes a while to get used to. ( I wasn't a fan) but one of the cool parts about doing nights first is that sometimes you get to see some of the patients you took care of when they were first admited.

S,Sn,M,F - finish up all the order changes to the patients you saw in the morning, write discharge summaries for patients that will be going home that evening or the next day. Depending on which PA your working with the rest of the day is spent learning either from quizing or lecture or it's your time and you can study, enter typhon, watch TV, take a nap, or blog :)

the night shift...

The Trauma night shift has been quite the roller coaster ride for me. Extremely mixed emotions, some very low, lows and happy highs.

The highs:

Lot's of learning: managing ventilator patients, Hyponatremia protocols, calculating a FeNa, indications for exploratory laparotomies, ECMO, Normal pressure hydrocephalus, CIWA protocols, evaluating a trauma, and the list goes on and on...

Procedures to do: Inserting a foley catheter into a ruptured bladder with vaginal fistula, Retrograde urethragram, Femoral stick ABG, lots of sutures and stapling. helping with chest tubes, Arterial line and exploratory laparotomy.

Seeing really cool injuries - Giant scalp laceration I could stick my entire hand down, stab wound to the neck, unfortunate C-spine fractures with spinal cord involvement ( jury's out on future paralysis) fractured pelvis, subdural and subarachnoid hematoma's, X-ray of roofing nails from a nail gun to the chest and heart!!! (I didn't actually see this patient but the x-ray was pretty impressive by itself)

Super awesome preceptors, who are smart and fun and happy to teach.

the Low's:

Mostly consist of my own inner dialog berating myself for not knowing the answers to questions, (especially the one's I actually DO know but somehow fail me when under pressure).

and the worst

The Attending who's displeasure with me was palpable. First he ignores me, then asks my preceptor why I'm doing the ROS cause I "apparently don't know what's important". Then he tries to make me look like a fool because when I asked the patient "any surgeries" and they said "no" I foolishly reported a negative hx of surgeries, so he calls me out on it cause he knows the patient had some kind of abd surgery cause of a scar (which he found doing the PE, which only the Residents and Attending's do on a level I trauma) Yep that night was an all time low and I cried on the way home from the hospital in the morning. (luckily he's now on days and I have new Attendings who are AWESOME!!)

Overall trauma is shaping up to be every bit of the amazing rotation I thought it would be. I would love to work in trauma... someday but I think I'll need a few years under my belt before I feel confident enough to be there (I'm guessing less "impostor syndrome" anxiety for me).

TRAUMA!!!

Tomorrow I begin one of the most anticipated rotations scheduled! I am so excited I can barely contain myself!! As I understand it I'll show up at 6am get my scrubs, a tour and introduction to my new home for the next 6 weeks. I will then be sent home to sleep, so I can be ready for my 12 hour shift starting at 6pm ending at 6am. Yep that's right - Night shift straight out the gate! I'll be working at least 72hrs a week with Fridays off. I'm not sure how often I'll be blogging during this rotation as I'm told it's exhausting. So just keep your fingers crossed that gun shot wounds, stabbings, random accidents and MVA's have a slight increase over the next 6weeks.... but you people stay safe!